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Pelvic Pain and Pelvic Floor Dysfunction in Male Athletes

Authors:
POPULATION-SPECIFIC CONCERNSLindsey E. Eberman, PhD, ATC, LAT, Report Editor
Pelvic
Pain
and Pelvic Floor Dysfunction
in Male Athletes
Victor Liberi, MS, ATC, CSCS, STS Adrian College and Karen H. Liberi, MS, MPT, WCS
Carter Rehabilitation, Tecumseh Ml
Jr ELVIC pain and pelvic floor dysfunction
are terms often used to designate a wide
variety of conditions. Male "pelvic pain" is
typically associated with the reproductive
organs, the renal system, and their sup-
porting structures, which may affect the
abdomen, rectum, genitalia, or perineum,
whereas "pelvic floor dysfunction" is a term
associated with the abnormal function of
the organs within the
pelvis, the reproduc-
tive organs, the pelvic
floor musculature, or
associated structures
of the perineum. A
consensus definition
that distinguishes
pelvic pain from pelvic
floor dysfunction has
not been reached, and
their respective etiolo-
gies have not been clearly identified.
'
Sacro-
iliac dysfunction may be related, but it is not
typically included as a component of pelvic
pain or pelvic floor dysfunction.
Pelvic pain occurs in 4% of men in the
third decade of life and 5.3
%
of those in the
fourth decade of life.^ Nickel et al. reported
that 9.7
%
of men suffer from prostatitis-like
symptoms at some point in life.' No research
has established the prevalence of pelvic floor
dysfunction among male athletes." With
increasing participation in rodeo, equestrian
sports, and extreme sports (e.g., skateboard-
KEY
POINTS
Pelvic pain
and
pelvic floor dysfunction are
becoming more prevalent.
ATs
should be knowledgeable about acute
and chronic injuries to the pelvic
floor.
Rehabilitation
is an
option for management
of pelvic floor dysfunction in male athletes.
ing, snowboarding, and BMX cycling), inju-
ries to the pelvic floor and perineum are likely
to become more prevalent. Athletic trainers
and therapists should know about acute and
chronic pathologies that may be classified as
pelvic pain, with or without associated pelvic
floor dysfunction.
Although numerous conditions may be
classified as either a pelvic pain syndrome
or pelvic floor dysfunction, this report will
focus on those that are most common among
male athletes. Lower urinary tract symptoms
(LUTS), prostatitis, and pudendal neuralgia
are the most common causes of pelvic pain
and pelvic
floor
dysfunction in male athletes.^
Acute Perineal Trauma
The common characteristic of acute perineal
trauma appears to be a "straddle" mecha-
nism of injury Acute perineal injuries have
been reported in skateboarding, horseback
riding, and bull riding,^•'' but most urologie
research pertaining to sports has related to
cycling. Urethritis, hematuria, testicular tor-
sion, and impotence associated with cycling
have been thoroughly documented.^ A few
reports have documented trauma to the
perineum as a result of impact against the top
tube or handle bar of a bicycle,^''° but none
of them have addressed chronic symptoms
related to pelvic floor dysfunction.
Priapism, a prolonged penile erection
that is unrelated to arousal, has been docu-
(DZOII
Human Kinetics-ATT
16(1),
pp.
8-IZ
8 I JANUARY 2011INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
mented to be a relatively rare acute condition associ-
ated with cycling.^" Two forms of priapism are rec-
ognized: (a) veno-occlusive, or low-flow, priapism and
(b) arterial, or high-flow, priapism. Low-flow priapism
is the more common condition, which results from
obstruction to venous outflow following treatment for
erectile dysfunction (ED).^ High-flow priapism results
from perineal or penile trauma that injures the cavern-
ous artery, thereby increasing penile blood flow.^ The
time from injury to manifestation of symptoms may
be prolonged (i.e., four hours to two days), but the
condition should be treated as an emergency.**
Chronic Perineal Trauma
and Pudendal Neuralqia
Pudendal neuralgia is typically a chronic condition that
involves sharp or stabbing pain along the distribution
if the pudendal nerve, which may be associated with
urinary or pelvic floor dysfunction.'^'^ The pudendal
nerve originates from the sacral plexus (i.e., S2-S4).'''
It passes through the greater sciatic foramen, and
it lies between the sacrotuberous and sacrospinous
ligaments." As it emerges from these two ligaments,
it passes through the pudendal canal (Alcock's canal)
just inferior to the insertion of the sacrotuberous liga-
ment. The nerve then extends to the area of the pubis
and divides into branches.'•* The pudendal nerve is
primarily a sensory nerve that has three terminating
branches: (a) inferior rectal, (b) perineal, and (c) dorsal
penile." This nerve innervates the area from the medial
aspect of the ischial tuberosity to the tip of the penis,
including the anus, perineum, and scrotum. Pudendal
neuralgia may affect any one of the nerve branches,
or all of them (Figure
1
).
aao^naia ligament
pudendal nerve
lesser sciatic notch
SBUUtubauB
jnfericruul nenx
deep perioeal nave
superficial perineaJ nerve
poÊtaiot iciatal nerves
Figure I The pudendal nerve.
Wikimedia Commons: http://commons.wikimeclia.org/wiki/File:Pudendal_
nerve.svg#ftlehistory. By Mikael Häggström. public domain.
ormis
Several factors may contribute to dev
the condition. Tightness, spasm, or inflamrjnation
levator ani, obturator internus, and pirif(
may constrict the pudendal nerve, and tig
sacrotuberous and the sacrospinous lig£
entrap the nerve.'^ During the skeletal
of a highly active adolescent male, hypert
pelvic floor muscles may cause increase
the ischial spine or alter its position, theret
Alcock's canal.'^ Spasm or inflammation o
or anus, associated with irritable bowel
internal hemorrhoids, and anal
fissures,
m
to the scrotum or penis.'' The chronic na
and discomfort from pudendal nerve trauma
hypertonicity of the pelvic floor musculatu
tion of the pain-spasm cycle is a treatm
this condition." Manual therapy, in conji
biofeedback and behavioral modification
ate pressure on the pudendal nerve, there
pain and dysfunction.''
Alcock's Syndrome is caused by repeti
on the perineum, which produces transien
or hypesthesia of the penis and/or scrot
arterial insufficiency is another possib
genital numbness and ED. These sympt
long-lasting when caused by repetitive rr
Incorrect saddle position for cycling is
cause of Alcock's syndrome.''' Managen-
include saddle adjustment or change in sa
medication, rehabilitation, pudendal ner\
and pudendal decompression surgery."
Lower Urinary Tract
Sympto ms
Pelvic floor dysfunction may be associated with lower
urinary tract symptoms
(LUTS),
which include frequent
urination, urgency, nocturia, intermittent or decreased
urine flow, and a sensation of incomplete bladder
emptying.'^
LUTS
is most commonly diagnosed in men
secondary to prostatitis or benign prostat c hyperpla-
sia (BPH).'" BPH involves cellular prolifenition in the
periurethral zone of the prostate. The prost îte begins a
second growth spurt at age 25 and contin jes to grow
throughout life. Typically, the rate of growth is slow,
and symptoms of BPH do not develop until 40 years
of age or
later.
"^
Although BPH and
LUTS
often coexist,
the relationship between the conditions is unclear.'^
Medication can negatively affect the renal system
in young healthy men. Narcotic pain medication may
disrupt the neuromuscular control of the bladder by
lopment of
of the
muscles
ness of the
nents may
îvelopment
ophy of the
the size of
narrowing
the rectum
syndrome,
y refer pain
ure of pain
can cause
. Interrup-
nt goal for
nction with
may allevi-
reducing
ve pressure
paresthesia
m.'" Penile
cause of
ms may be
icrotrauma.
a common
;nt options
die design,
e injection.
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAININGJANARY2011 19
reducing
the
void reflex
and
causing some degree
of
urinary retention.'^ Diuretics
are
often used
in the
treatment of hypertension, which can create urination
urgency. The use
of
non-diuretic medication will likely
alleviate
the
problem.'^
Prostatitis
The prostate gland
is a
walnut-sized structure that
is
part
of the
male reproductive system. Although
the
function of the prostate is not fully understood, its main
role
is to add
fluid
to the
sperm during ejaculation.'"*
Unfortunately, prostatitis
is
often used
as a
catch-all
term
to
collectively designate conditions that may
or
may
not
involve inflammation
of the
prostate gland.
The traditional definition
of
prostatitis
may
include
acute bacterial infection, fever, voiding dysfunction,
ejaculation pain,
or
pain in the urethra, penis, scrotum,
low back, abdomen, or perineum that persists for more
than three months.-^" The National Institute
of
Health
has classified prostatitis in four categories (Table
1).^'^^
The most important distinction between
the cat-
egories
of
prostatitis
is the
presence
or
absence
of
bacterial infection. Bacterial prostatitis
is the
leading
cause
of
urinary tract infections
in
men.''° Antibiotics
are often prescribed, which
are
effective
for
treat-
ment of bacterial prostatitis.^" The majority
of
patients
diagnosed with prostatitis (90%
or
greater) have non-
bacterial prostatitis (category HI)." This population
of
prostatitis patients may
be
classified
as
having any of
the following synonymous conditions: chronic pelvic
pain syndrome (CPPS), urologie chronic pelvic pain
syndrome (UCPPS), pelvic pain syndrome (PPS),
or
chronic prostatitis (CP; see Table
2).
Because CPPS (Prostatitis
III and IV) is
poorly
understood, its treatment is non-specific. Among men
younger than
50
years
of
age,
11
% suffer from CPPS
or prostatitis-like symptoms.'" Little research
has
assessed
the
accuracy
of
CPPS diagnoses, because
TABLE 1 NIH CLASSIFICATIONS
FOR PROSTATITIS
TABLE 2 COMMONLY USED
TERMINOLOGY FOR PELVIC PAIN
AND URINARY DYSFUNCTION
Prostatitis
Prostatitis
Prostatitis
Prostatitis
Prostatitis
1
II
Ilia*
lllb*
IV
Acute bacterial
prostatitis
Chronic
bacterial
prostatitis
Chronic nonbacterial prostatitis
Chronic
pelvic
pain
syndrome
Asymptomatic
prostatitis
Term
Chronic
Pelvic
Pain
Syndrome
Urologie Chronic
Pelvic
Pain
Syndrome
Pelvic
Pain
Syndrome
Chronic Prostatitis
Lower
Urinary Tract
Symptoms
Abnormal
voiding
Abbreviation
CPPS
UCPPS
PPS
CP
LUTS
Definition
Prostatitis
111,
Prost-
adynia
Prostatitis
111.
Prost-
adynia
Prostatitis
111,
Prost-
adynia
Prostatitis
11,
Prosta-
titis
III
Urinary
dysfunc-
tion/
'
Distinguishing between MIA
and
IIIB
has no
clinical significance
symptoms
are
vague
and its
etiology
not
well under-
stood. Diagnostic tests are
not
often utilized, because
they
are
difficult, uncomfortable,
and
expensive
to
perform.^" CPPS
is
idiopathic and its diagnosis
is
typi-
cally based exclusively on symptoms." CPPS may have
a cause that
is
external
to the
prostate gland, such
as
a bladder outflow
or
pelvic floor muscle disorder.^"
Beneficial therapeutic effects derived from rehabilita-
tion, manual therapy,
and
biofeedback may relate
to
the involvement
of
pelvic floor musculature
in the
etiology
of
CPPS.'-^-"
Treatment
Although rehabilitation, manual therapy, and biofeed-
back have been reported
to
provide positive results
for
the
treatment
of
pelvic pain
and
pelvic floor dys-
function, clinicians who possess specialized expertise
are difficult
to
locate."'-^'''^'''^*' Myofascial pain
and its
corresponding treatment
are
extremely common
in
athletic health care. Manual therapy
for
myofascial
release
and
trigger point desensitization
is
becoming
more common
in the
urologie community. Zermann
et al.'" reported
an
inability
to
contract
and
relax
the
pelvic floor muscles
in
88%
of
their patient sample
and suggested that compromise
of the
pelvic floor
musculature
may
cause bladder hypertonicity, pain,
urgency,
and
undesirable changes within
the
central
nervous system. Anderson
et
al.
^'^
reported moderate
to marked improvement
of
CPPS symptoms among
72
%
of
patients
who
received manual therapy
and
education.
10
I
JANUARY 2011
INTERNATIONAL
JOURNAL OF ATHLETIC THERAPY
&
TRAINING
Athletes referred for treatment of pelvic pain or
pelvic floor dysfunction should anticipate an evalua-
tion that will include acquisition of
a
thorough medical
history and in-depth inquiry about conditions that may
have contributed to the onset of symptoms. Biofeed-
back testing may be performed to obtain baseline
measurements of the status of the pelvic floor mus-
culature, including activation level at rest, ability to
voluntarily contract and relax, and fatigue (Figure 2).''
The evaluation should include assessment of lumbo-
sacral function and lower extremity flexibility and both
external and internal examination of the pelvic floor
musculature.
Biofeedback is also used as a treatment modality
to minimize hypertonicity and to restore control of the
pelvic floor musculature.' External manual therapy
can be utilized if internal techniques are too painful.
Although the treatment of this population is compli-
cated and multilayered, in pelvic pain patients, the
obturator internus
(OI)
often requires attention. Manual
therapy that is focused on the 01 muscle is often indi-
cated, because it encircles the pudendal nerve. This
muscle can be externally accessed by positioning the
patient in a side-lying posture on the unaffected side
(i.e.,
affected side directed upwardly). The clinician
can palpate the ischial tuberosity, and then angle the
hand supero-laterally to locate the Ol muscle (Figure
3).
To ensure proper hand placement, the practitioner
should instruct the patient to provide resistance to
manual external rotation, which
will
produce a palpable
contraction of the Ol muscle.''
For internal pelvic floor manual therapy, the patient
should be positioned on the unaffected side, with the
upper knee pulled toward the chest, thereby facilitating
internal rotation of the hip. The clinician locates the
Ol muscle by palpating the lateral wall of the pelvis
within the rectum and providing manual resistance to
external rotation of the upper hip (Figure 4)."
Figure Z Biofeedback testing.
3 External manual therapy for the obturator i
Figure 'i Internal manual therapy for the obturator internus.
Summary
Pelvic pain and pelvic floor dysfunction
¿
ffects male
athletes. More research is needed to better understand
the etiologies of these conditions and their impact on
male athletes. Athletic trainers and theripists need
to be aware of symptoms and treatmeni options to
effectively manage the varied conditions that may be
classified as a pelvic pain syndrome or pelvic floor
dysfunction. I
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Victor Liberi is a certified athletic trainer and assistant professor of
athletic training at Adrian College in Adrian, Ml.
Karen Liberi is a physical therapist with a women's health clinical
specialist certification. She treats exclusively LUTS and CPPS in men
and women for Carter Rehabilitation in Tecumseh, Ml.
12 I JANUARY 2011INTERNATIONAL JOURNAL OF ATHLETIC THERAPY &. TRAINING
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Article
Introduction: the Pudendal Nerve Entrapment Syndrome was described for the first time by Gérard Amarenco in 1987. It is caused by several etiologies and is characterized by neuritic pain located in the genital, perineal, and anal areas. Sexual, urinary and fecal dysfunctions could accompany the pain. It is often misdiagnosed in the clinical setting. Objective: to sensitize the health care provider on the diagnosis and treatment of the Pudendal Nerve Entrapment Syndrome and its impact on sexual health. Methods: The clinical method was applied by performing a detailed history and a thorough physical examination, with emphasis on the pelvic floor, in addition to further examination. A specialized literature review was conducted. Results: the history and physical examination entailed the presumptive diagnosis of pudendal nerve injury. This study revealed the presence of bilateral pudendal nerve injury by electrophysiological studies. Conclusiones: this case shows bilateral pudendal nerve injury, after performing a hysterectomy. The development of neuropathic pain generating an apparent increase in sexual desire with increased sexual activity in a postmenopausal woman is documented. The need to prevent nerve injury during pelvic surgery and its impact on sexuality is highlighted.
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A man riding a stationary bicycle experienced transient tight sensations around the head of his penis during the exercise and progressive impairment of sexual potency over a period of more than one year. Lowering the bicycle seat terminated the bouts of impaired penile sensation, and one month after the patient discontinued the bicycle exercises, sexual potency returned. The course supported an ischemic mechanism for the abnormal penile sensation and a neural mechanism for impotence. Impotence has been associated with both vascular and neural lesions, and there is evidence for both vascular and neural compression in the perineal area during bicycle riding. A relationship between sexual dysfunction and bicycling may be more common than formerly suspected.
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Pelvic pain remains a challenging urological problem. Because antimicrobial therapy is often unsuccessful for relieving symptoms, it is reasonable to question whether pelvic pain is the result of microbiological versus functional pelvic disease. We analyzed clinical and urodynamic findings to evaluate the role of pelvic floor dysfunction in patients with pelvic pain. We retrospectively evaluated history, physical examination and urodynamic studies in 103 men with an average age of 47 years who presented with pelvic pain between August 1994 and August 1997. In all patients microbiological tests were negative before study entry. The reported locations of pain were the prostate and/or perineal region in 45.6% of cases, scrotum and/or testis in 38.8%, penis in 5.8%, bladder in 5.8%, and lower abdomen and lower back in 1.9% each. Previous treatment consisted of 1 to 12 courses of antibiotics in the preceding 6 to 36 months. In 88.3% of the patients there was pathological tenderness of the striated muscle with poor to absent pelvic floor function. Urodynamics were performed in 84 cases. Cystometry was normal except for decreased compliance in 5 patients. Abnormal findings were mostly evident in the coordination of voiding and in dynamic sphincter-pelvic floor activity. Average sphincter pressure was increased to 104.9 cm. water in 72.6% of the patients, average peak urine flow was decreased to 9.9 ml. per second in 61.9% and functional urethral length was increased to greater than 35 mm. in 79.8%. Urethral profile pattern was dysfunctional, obstructed, and combined dysfunctional and obstructed in 52.4, 11.9 and 21.4% of the cases, respectively, while in 88.1% urethral sensitivity was minimally or markedly increased. Since activity is a reflection of neural control, the apparent association of pelvic floor dysfunction with pelvic pain raises the probability of a primary or secondary central nervous system breakdown in the regulation of pelvic floor function. This hypothesis is supported by the improvement in symptoms caused by therapy aimed at modulating the pelvic floor, such as biofeedback, medication and sacral anterior root stimulation.
Article
The term prostatitis is applied to a series of disorders, ranging from acute bacterial infection to chronic pain syndromes, in which the prostate gland is inflamed. Patients present with a variety of symptoms, including urinary obstruction, fever, myalgias, decreased libido or impotence, painful ejaculation and low-back and perineal pain. Physical examination often fails to clarify the cause of the pain. Cultures and microscopic examination of urine and prostatic secretions before and after prostatic massage may help differentiate prostatitis caused by infection from prostatitis with other causes. Because the rate of occult infection is high, a therapeutic trial of antibiotics is often in order even when patients do not appear to have bacterial prostatitis. If the patient responds to therapy, antibiotics are continued for at least three to four weeks, although some men require treatment for several months. A patient who does not respond might be evaluated for chronic nonbacterial prostatitis, in which nonsteroidal anti-inflammatory drugs, alpha-blocking agents, anticholinergic agents or other therapies may provide symptomatic relief.
Article
Pelvic floor tension myalgia may contribute to the symptoms of male patients with chronic pelvic pain syndrome (CPPS). Therefore, measures that diminish pelvic floor muscle spasm may improve these symptoms. Based on this hypothesis, we enrolled 19 patients with CPPS in a 12-week program of biofeedback-directed pelvic floor re-education and bladder training. Pre-treatment and post-treatment symptom assessments included daily voiding logs, American Urological Association (AUA) symptom score, and 10-point visual analog pain and urgency scores. Pressure-flow studies were obtained before treatment in most patients. Instruction in pelvic floor muscle contraction and relaxation was achieved using a noninvasive form of biofeedback at biweekly sessions. Home exercises were combined with a progressive increase in timed-voiding intervals. Mean age of the 19 patients was 36 years (range 18 to 67). Four patients completed less than three treatment sessions, 5 patients completed three to five sessions, and 10 attended all six sessions. Mean follow-up was 5.8 months. Median AUA symptom scores improved from 15.0 to 7.5 (P = 0.001), and median bother scores decreased from 5.0 to 2.0 (P = 0.001). Median pain scores decreased from 5.0 to 1.0 (P = 0.001), and median urgency scores decreased from 5.0 to 2.0 (P = 0.002). Median voiding interval increased from 0.88 hours to 3.0 hours (P = 0.003). Presence of detrusor instability, hypersensitivity to filling, or bladder-sphincter pseudodyssynergia on pretreatment urodynamic studies was not predictive of treatment results. This preliminary study confirms that a formalized program of neuromuscular re-education of the pelvic floor muscles together with interval bladder training can provide significant and durable improvement in objective measures of pain, urgency, and frequency in patients with CPPS.